Basic Information
| Provider Information | |||||||||
| NPI: | 1144367111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAU | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5486 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928635486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
| FaxNumber: | 5052931524 | ||||||||
| Practice Location | |||||||||
| Address1: | 716 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912041010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
| FaxNumber: | 5052931524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 03/23/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 20A7545 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00AX75450 | 05 | CA | MEDICAID |